Rubella

A Newborn with Thrombocytopenia, Cataracts, and Hepatosplenomegaly

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How common is the use of the rubella vaccine worldwide?

The acronym TORCH (toxoplasmosis, other [syphilis, varicella, parvovirus B19 infection, HIV infection], rubella, cytomegalovirus infection, and herpes simplex virus infection) is often used to identify possible congenital infections.

Clinical Pearls

Q: What are some of the clinical manifestations of the congenital rubella syndrome?

A: Cataracts, thrombocytopenia, bony abnormalities, and deafness are consistent with the congenital rubella syndrome.

Table 2. (10.1056/NEJMcpc1706110/T2) Manifestations of the Congenital Rubella Syndrome.

Q: How is the congenital rubella syndrome diagnosed?

A: Newborns with the congenital rubella syndrome shed rubella virus in the throat, nasopharynx, and urine. Because growth of the virus in cultured mammalian cell lines is relatively slow and cultivation and identification of the virus are labor-intensive, nucleic acid amplification tests have been developed to directly detect rubella virus RNA in clinical samples.

Morning Report Questions

Q: Can serologic testing also establish the diagnosis of the congenital rubella syndrome?

A: In addition to direct viral detection, evidence of the production of antibodies to rubella virus in an infant can be used to establish a diagnosis of the congenital rubella syndrome. Affected newborns produce IgM antibodies to rubella virus. These antibodies can usually be detected at birth with the use of a capture enzyme-linked immunosorbent assay; the level increases during the first 3 months of life and then declines over time. At birth, tests for IgG antibodies to rubella virus cannot be used to distinguish between transplacentally acquired maternal antibodies and antibodies produced by the neonate. However, another means of establishing a diagnosis of the congenital rubella syndrome is showing that the level of IgG antibodies to rubella virus does not substantially decrease during the first few months of life, as the maternal antibodies decay. Finally, IgG antibodies to rubella virus that are produced by infants with congenital infection are typically of low avidity; therefore, a diagnosis of the congenital rubella syndrome can be established by detecting low-avidity antibodies in the blood after the maternal antibodies have waned.

Q: How common is use of the rubella vaccine worldwide?

A: The estimated number of cases of the congenital rubella syndrome worldwide is still approximately 100,000 per year. Rubella and the congenital rubella syndrome have been eradicated from the Western hemisphere because of good vaccine coverage. Unfortunately, although rubella has been controlled in many countries in Europe, opposition to vaccination in some countries has prevented the elimination of rubella, and there is much work to be done. In contrast, routine vaccination against rubella has just begun in some Asian countries, including India, Thailand, China, Japan, and Indonesia. Coverage in Africa is spotty, but a few countries have introduced the vaccine. In Nigeria, vaccination is limited to private providers, and coverage is less than 10%. There is a campaign to introduce the combined measles–rubella vaccine throughout the world, and all regions have goals to eradicate both diseases.

Measles outbreak across Europe

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Measles

Measles is spreading across Europe wherever immunisation coverage has dropped, the World Health Organization is warning.

The largest outbreaks are being seen in Italy and Romania.

In the first month of this year, Italy reported more than 200 cases. Romania has reported more than 3,400 cases and 17 deaths since January 2016.

Measles is highly contagious. Travel patterns mean no person or country is beyond its reach, says the WHO.

For good protection, it’s recommended that at least 95% of the population is vaccinated against the disease.

But many countries are struggling to achieve that.

Most of the measles cases have been found in countries where immunisation has dipped below this threshold and the infection is endemic – France, Germany, Italy, Poland, Romania, Switzerland and Ukraine.

Preliminary information for February suggests that the number of new infections is rising sharply, says the WHO.

WHO regional director for Europe Dr Zsuzsanna Jakab said: “I urge all endemic countries to take urgent measures to stop transmission of measles within their borders, and all countries that have already achieved this to keep up their guard and sustain high immunisation coverage.”

The European Centre for Disease Prevention and Control says that between 1 February 2016 and 31 January 2017 the UK reported 575 cases of measles.

The MMR (measles, mumps and rubella) vaccine is available on the NHS for babies and pre-school children.

Lagging immunisation

Robb Butler, of the WHO Regional Office for Europe, says there are a number of reasons why vaccination coverage has waned in some regions.

“In some countries, like the Ukraine, there have been supply and procurement issues.”

Then there’s vaccine hesitancy. Some people are fearful of vaccination, while others are complacent or find it an inconvenience, he says.

In France, for example, people need to make an appointment with their doctor to get a prescription, go to the pharmacy to collect the vaccine and then rebook with their doctor to have the jab administered.

“We need to get to the point where we appreciate that people have busy lives and competing priorities.”

Dr Mary Ramsay, Head of Immunisation at Public Health England, said: “England’s uptake of MMR vaccine by five years of age has reached the WHO’s target of 95%.

“In the last year, the measles cases confirmed in England have mainly been in older adolescents and young adults with many linked to music festivals and other large public events. Individuals of any age who have not received two doses of the MMR vaccine, or those who are unsure, should speak to their GP – it’s never too late to have the vaccine and measles can still be serious in adults. We are continuing to invest in programmes which encourage uptake of the vaccine to ultimately consign measles to the history books.”

Measles

  • Unvaccinated young children are at highest risk of measles and its complications, including death
  • Measles is spread by direct contact and through the air by coughs and sneezes
  • The virus remains active and contagious on infected surfaces for up to two hours
  • The first signs of infection are usually a high fever and cold-like symptoms, such as a runny nose
  • You may notice small white spots on the inside of the cheeks as well
  • After several days, a rash develops, usually on the face and neck first and then spreading to the body and limbs
  • An infected person can pass on the virus to others from four days prior to developing the skin rash to four days after the rash erupts
  • There is no treatment, but two doses of vaccine can prevent infection in the first place

Source:BBC

Vaccines for adults: Which do you need?

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Vaccines offer protection from various types of infections and diseases, from seasonal flu to diphtheria. Understand which vaccines adults need and when to get them.

Wonder which vaccines you need? It can be confusing, especially if you thought vaccines were just for kids. Use the list below to find out which vaccines you need now and which vaccines might be coming up — based on recommendations from the Centers for Disease Control and Prevention.

Seasonal influenza (flu)

Seasonal flu is a viral infection that affects the respiratory system. Potentially serious — even life-threatening — complications of the flu are possible.

Who needs it
The flu vaccine is recommended for all adults — unless you had a severe reaction to a previous flu vaccine or you’re currently ill. The flu vaccine is available as a shot or a nasal spray.

If you’re pregnant, choose the flu shot vaccine — not the nasal spray vaccine. If you’re age 65 or older, ask your doctor about a high-dose flu shot. Consult your doctor before getting a flu vaccine if you’ve had Guillain-Barre syndrome or you have a severe allergy to eggs.

When to have it
Get one dose of the flu vaccine every year, ideally in September or as soon as the vaccine is available.

Pneumococcal disease

Pneumococcal disease is a potentially serious infection caused by a type of bacteria called pneumococcus. Pneumococcal disease can take various forms, including pneumococcal pneumonia and pneumococcal meningitis. Pneumococcus also causes infections in the bloodstream.

Who needs it
Get the pneumococcal polysaccharide vaccine — the type of pneumococcal vaccine available for adults — if:

  • You’re age 65 or older
  • You have a weak immune system
  • You have a chronic illness, including asthma, lung disease, liver disease or diabetes
  • You’ve had your spleen removed
  • You live in a long term care facility
  • You smoke

Don’t get the vaccine if you had a severe reaction to a previous dose of the vaccine or you’re currently ill.

When to have it
Get one dose of the pneumococcal vaccine at any time. Ask your doctor if you need a second dose.

Tetanus, diphtheria and pertussis

Tetanus, diphtheria and pertussis are bacterial infections. Tetanus, sometimes called lockjaw, affects the nervous system, leading to painful muscle contractions — especially in the jaw and neck. Diphtheria is a respiratory disease that can lead to difficulty breathing. Whooping cough (pertussis) causes cold-like signs and symptoms and a persistent hacking cough.

Who needs it
Get the combined tetanus toxoid, reduced diphtheria and acellular pertussis (Tdap) vaccine if you haven’t received the vaccine in the past or don’t know if you’ve received the vaccine.

The Tdap vaccine isn’t recommended if you had a severe reaction to a previous dose of the tetanus-diphtheria (Td) series or Tdap vaccine, you experienced a coma or seizures within seven days of a previous dose of the vaccine or you’re currently ill. Consult your doctor before getting the Tdap vaccine if you have epilepsy or you’ve had Guillain-Barre syndrome.

When to have it
Get one dose of the Tdap vaccine if you didn’t finish the Td series as a child or don’t know if you ever had the Td vaccine. Get a second dose four weeks after the first dose. Get a third dose six to 12 months after the second dose.If you’re due for a Td booster — recommended every 10 years — but haven’t previously received Tdap, get one dose of the Tdap vaccine at any time followed by a Td booster every 10 years.

Meningitis

Meningitis is an inflammation of the membranes surrounding the brain and spinal cord.

Who needs it
Get the meningitis (meningococcal) vaccine if:

  • You didn’t have the vaccine as a child or adolescent and you’re living in a dormitory for the first time
  • You travel to or work in parts of the world where meningitis is common
  • You’re joining the military
  • You had your spleen removed
  • A meningitis outbreak occurs in your community

The meningitis vaccine isn’t recommended if you had a severe reaction to a previous dose of the vaccine or you’re currently ill.

When to have it
Get one dose of the meningitis vaccine at any time — or a booster dose if you’re a first-year college student up to age 21 and first had the vaccine before age 16. Get a second dose eight weeks later if you have certain health conditions, such as HIV.

Chickenpox (varicella)

Chickenpox is a highly contagious infection that causes a red, itchy rash. Complications can include a bacterial infection of the skin, an infection in the bloodstream, pneumonia or inflammation of the brain (encephalitis).

Who needs it
Get the chickenpox vaccine if:

  • You didn’t have the vaccine as a child or adolescent or you’ve never hadchickenpox — especially if you live with someone who has a weak immune system
  • You aren’t sure whether you’ve had chickenpox
  • You’re considering pregnancy and don’t know if you’re immune to chickenpox

The chickenpox vaccine isn’t recommended if you had a severe reaction to a previous dose of the vaccine or to gelatin or the antibiotic neomycin, you’re currently ill, you’re pregnant or you have a weak immune system.

When to have it
Get one dose of the chickenpox vaccine at any time. Get a second dose at least four weeks after the first dose.

Measles, mumps and rubella

Measles, mumps and rubella are viral infections. Measles causes a red, blotchy skin rash. Complications can include ear infection, pneumonia and inflammation of the brain (encephalitis). Mumps causes swelling in the salivary glands, located below and in front of your ears. Rubella, also called German measles, causes a distinctive red rash. Rubella is most serious if it develops during pregnancy.

Who needs it
Get the combined measles-mumps-rubella (MMR) vaccine if you were born during or after 1957 and didn’t have the vaccine as a child or adolescent.

The MMR vaccine isn’t recommended if you had a severe reaction to a previous dose of the vaccine or to gelatin or the antibiotic neomycin, you’re currently ill, you’re pregnant, you have a weak immune system, or you recently had a blood transfusion.

When to have it
Get one dose of the MMR vaccine at any time. Get a second dose at least four weeks after the first dose if you’re a health care worker, you travel internationally, you’re a college student, or you had a rubella blood test that shows no immunity.

Human papillomavirus

Genital human papillomavirus (HPV) is a common sexually transmitted infection. Most people who have HPV don’t develop symptoms. For some people, however, an HPV infection can lead to genital warts or, for women, cervical cancer.

Who needs it
Get the human papillomavirus (HPV) vaccine if:

  • You’re a woman age 26 or younger and didn’t have the vaccine as an adolescent
  • You’re a man age 21 or younger and didn’t have the vaccine as an adolescent — although men can get the vaccine through age 26, if desired

The HPV vaccine isn’t recommended if you had a severe reaction to a previous dose of the vaccine, you have a severe allergy to yeast or latex, you’re pregnant, or you’re currently ill.

When to have it
Get one dose of the HPV vaccine at any time. Get a second dose one to two months after the first dose, and a third dose six months after the first dose.

Hepatitis A

Hepatitis A is a potentially serious liver infection.

Who needs it
Get the hepatitis A vaccine if:

  • You want to protect yourself from hepatitis A
  • You have a clotting-factor disorder or chronic liver disease
  • You’re a man who has sex with men
  • You inject illicit drugs
  • You’re a health care worker who might be exposed to hepatitis A in a lab setting
  • You travel to or work in parts of the world where hepatitis A is common

The hepatitis A vaccine isn’t recommended if you had a severe reaction to a previous dose of the vaccine, you have a severe allergy to latex or you’re currently ill.

When to have it
Get one dose of the hepatitis A vaccine at any time. Get a second dose six at least six months after the first dose.

Hepatitis B

Hepatitis B is another type of liver infection. For some people, hepatitis B becomes chronic — leading to long-term liver problems.

Who needs it
Get the hepatitis B vaccine if:

  • You want to protect yourself from hepatitis B
  • You’re sexually active but not in a mutually monogamous relationship
  • You’re a man who has sex with men
  • You have close contact or sex with a person infected with hepatitis B
  • You inject illicit drugs
  • You’re receiving hemodialysis
  • You’re a health care or public safety worker who might be exposed to infected blood or body fluids
  • You live with someone who has a chronic hepatitis B infection
  • You travel to or work in parts of the world where hepatitis B is common
  • You’re age 59 or younger and have type 1 or type 2 diabetes and haven’t received the hepatitis B vaccine

If you’re age 60 or older and have diabetes, ask your doctor if the hepatitis B vaccine is right for you. The hepatitis B vaccine isn’t recommended if you had a severe reaction to a previous dose of the vaccine, you have a severe allergy to yeast or you’re currently ill.

When to have it
Get one dose of the hepatitis B vaccine at any time. Get a second dose one month after the first dose. Get a third dose at least two months after the second dose and at least four months after the first dose.

Shingles (herpes zoster)

Shingles is a viral infection that causes a painful rash. Anyone who has recovered from chickenpox might eventually develop shingles.

Who needs it
Get the shingles vaccine if you’re age 60 or older.

The shingles vaccine isn’t recommended if you’re currently ill, you had a severe reaction to gelatin or the antibiotic neomycin, you have a weak immune system or you’re pregnant.

When to have it
Get one dose of the shingles vaccine at any time.

Haemophilus influenzae type b (Hib)

Hib is a bacterium that causes potentially serious infections, including pneumonia, meningitis and swelling of the piece of cartilage that covers the windpipe (epiglottitis).

Who needs it
Get one dose of the Haemophilus influenzae type b (Hib) vaccine if:

  • You have certain health conditions, such as sickle cell disease, leukemia or HIV
  • You had your spleen removed

The Hib vaccine isn’t recommended if you had a severe reaction to a previous dose of the vaccine or you’re currently ill.

When to have it
Get one dose of the Hib vaccine at any time.

Source: Mayo Clinic.